CHOOSING A TREATMENT
FOR KIDNEY FAILURE
www.kidney.org
National Kidney Foundation's
Kidney Disease Outcomes Quality Initiative
Did you know that the National Kidney Foundation’s Kidney
Disease Outcomes Quality Initiative (NKF-KDOQI™) offers
guidelines and commentaries that help your doctor and
healthcare team make important decisions about your medical
treatment? The information in this booklet is based on those
recommended guidelines.
What is your stage of kidney disease?
There are 5 stages of kidney disease. They are shown in the
table below. Your doctor determines your stage of kidney
disease based on the presence of kidney damage and your
glomerular filtration rate (GFR), which is a measure of your level
of kidney function. Your treatment is based on your stage of
kidney disease. Speak to your doctor if you have any questions
about your stage of kidney disease or your treatment.
STAGES OF KIDNEY DISEASE
Stage
Description
Glomerular Filtration Rate (GFR)*
1
Kidney damage (e.g., protein
in the urine) with normal GFR
90 or above
2
Kidney damage with mild
decrease in GFR
60 to 89
3
Moderate decrease in GFR
30 to 59
4
Severe reduction in GFR
15 to 29
5
Kidney failure
Less than 15
*Your GFR number tells your doctor how much kidney function you have. As
chronic kidney disease progresses, your GFR number decreases.
TABLE OF CONTENTS
Kidney Failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Hemodialysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Peritoneal Dialysis. . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Kidney Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Living with Your Treatment Choice . . . . . . . . . . . . . 17
For More Information. . . . . . . . . . . . . . . . . . . . . . . . 24
If your doctor said you may need dialysis or a kidney
transplant soon, you are probably wondering how to
decide on the best choice for you. This booklet has general
information to help you and your family make this decision.
You should talk about the pros and cons of each treatment
option with your family, and healthcare professionals. They
will help you decide which treatment is best for you.
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Kidney Failure
What happens when your kidneys fail?
Your kidneys normally remove wastes and extra fluid from
your blood. When your kidneys fail because of disease
or injury, wastes and extra fluid can build up in your blood
and make you sick. You may have some of the following
symptoms:
•nausea
•trouble sleeping
•poor appetite
•fatigue
•hiccups
•dry, itchy skin
•weight loss
•muscle cramping at night
•abnormal bleeding or bruising easily
•swelling of your feet or ankles
•puffiness around your eyes
•anemia (low red blood cell count)
•trouble breathing or feeling short of breath
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When is treatment needed?
Your doctor will help you decide when you need to start
treatment. This decision is based on:
•your symptoms
•other health problems you have
•how much kidney function you have left
•your nutritional health
To help know when you need to start treatment, your
doctor should give you a simple blood test to estimate your
glomerular filtration rate (GFR). This tells how much function
your kidneys have.
How is GFR calculated?
Your doctor can estimate your GFR from the results of a
simple blood test for creatinine. Creatinine is a waste product
of your body’s muscle activity. Your kidneys usually keep the
level of creatinine just right. Your creatinine result is used in
a math formula with your age, race and gender to determine
your GFR.
If your GFR falls below 30, your doctor should give you
information about treatments for kidney failure. If your GFR is
below 15, you will need to start one of these treatments soon.
How do I know which treatment is best for me?
The two treatments for kidney failure are dialysis and kidney
transplantation. Two different kinds of dialysis can be done—
hemodialysis and peritoneal dialysis. Each type of treatment
has pros and cons. As you find out more about each one,
speaking with your doctor and your family can help you
decide which treatment is best for you.
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Your decision should be based on many things:
•medical condition
•lifestyle
•personal preference
No matter which treatment you choose, you need to make a
commitment to follow your treatment plan. This involves:
•following your treatment schedule
•following your special diet
•taking all your medicines as instructed
Following your treatment plan will help you live longer and
feel better.
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Hemodialysis
What is hemodialysis?
Hemodialysis is a treatment that removes wastes and extra
fluid from your blood. During hemodialysis, your blood is
pumped through soft tubes to a dialysis machine where it
goes through a special filter called a dialyzer (also called
an artificial kidney). As your blood is filtered, it is returned
to your bloodstream. Only a small amount of blood is out
of your body at any time. In order to be connected to the
dialysis machine, you need to have an access, or entrance,
to your bloodstream. (See page 12, “What is a hemodialysis
access?”) Treatments are usually done 3 times a week.
Each treatment lasts about 3 to 5 hours.
Where can I have hemodialysis treatment?
Hemodialysis treatments can be done at home or in a dialysis
center. Dialysis centers may be located within a hospital or
in a separate facility. You and your healthcare provider will
decide which place is best, based on your medical condition
and your wishes.
What is required to do hemodialysis at home?
Your home must have enough space for the equipment
and enough water drainage and electric power to operate
the dialysis machine and water purification unit. Medicare
may help cover the cost of minor changes to your home
for home hemodialysis.
You will also need a dialysis care partner. Usually this is a
family member or friend, but may also be someone you hire
to assist you. You and your partner will be trained in how to
do hemodialysis at home.
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Are there different types of home hemodialysis?
With home hemodialysis, you will have 3 different types of
treatment schedules to choose from. These choices are:
•Conventional home hemodialysis. Treatments are usually
done 3 times a week, and each treatment lasts about
3 to 5 hours.
•Short daily home hemodialysis. This involves more
treatments each week for shorter periods. For example,
you might do 6 treatments a week (compared with the
usual 3). Each treatment would last about 1½ to 2½ hours.
Many people feel that their quality of life improves with
this method of dialysis because they sleep better and
have better control of blood phosphorus levels, blood
pressure and anemia (low red blood cell count).
•Nocturnal (nighttime) home hemodialysis. This involves
long, slower treatments, which are done during the sleep
hours, usually for 6 to 8 hours. Many people sleep better
and have better control of blood phosphorus levels, blood
pressure, and anemia with this method of dialysis.
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Comparing Hemodialysis: At Home Versus in a Center
HOME HEMODIALYSIS
Advantages:
Disadvantages:
1.Dialysis is done in the
comfort of your own
home.
1.Space in the home needs
to be dedicated to the
machine, water system
(if needed) and supplies.
2.You do not need to travel
to a dialysis center.
3.You have more flexibility
to choose a time of day
to do dialysis.
4.You and your dialysis
partner learn how to do
treatments independent
of the center staff.
2.A dialysis partner must
be present while you are
on dialysis.
3.Both you and your
dialysis partner must take
time off work or regular
routine to attend training.
5.There is a greater sense
of control from having
independence with the
treatment schedule in
relation to your life and
work schedule.
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IN DIALYSIS CENTER
Advantages:
Disadvantages:
1.Trained staff performs
all aspects of treatment.
(You may be able to do
some things yourself,
like insert the needles.)
1.Treatment day and
times are scheduled
by the center.
2.Since other people are
dialyzing at same time,
friendships may develop.
2.You must travel to the
center at least three
times weekly.
3.Other people are doing
dialysis at same time,
so you have less privacy.
4.Loved ones may worry
if they can’t be with you
during treatment.
5.There may be rules
against eating and
drinking while on dialysis.
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What is a hemodialysis access?
If you choose hemodialysis, you need to have a permanent
access, or entrance, to your bloodstream. This is done with
minor surgery, usually to your arm.
There are three different types of access:
•Fistula
A fistula is the recommended choice
for an access. It is made by joining
an artery to a nearby vein under your
skin to make a bigger blood vessel.
Artery
This type of access is recommended
Fistula
because it has fewer problems and
lasts longer. You should be looked at
Vein
by a special doctor called a vascular
surgeon at least 6 months before you
will need to start dialysis. Your kidney
doctor or the surgeon may order an ultrasound evaluation
of your blood vessels to see the ideal ones for the fistula.
This is called “vessel mapping.” A fistula should be placed
early (several months before starting dialysis), so it has
plenty of time to heal and be ready for use by the time
you begin hemodialysis.
•Graft
Vein
Artery
If your blood vessels are not
suitable for a fistula, a graft may
be used. This involves joining an
artery and nearby vein with a
small, soft tube made of synthetic
material. The graft is entirely
beneath your skin.
Graft
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•Catheter
The third type of access, called
a catheter, is inserted into
a large vein in your neck or
chest. The ends of the tubes
sit on your skin outside your
body. This type of access is
generally used when you need
dialysis for a short period of
Catheter Tubes
time. Catheters are used as
a permanent access when a fistula or a graft cannot
be placed.
What happens after the fistula or graft heals?
After the fistula or graft has healed and dialysis
is started, two needles will be placed—one in the
artery side and one in the vein side of the access—
every time you have treatment. The needles are then
connected to soft plastic tubes. One tube carries
your blood from the needle to the dialyzer (the
artificial kidney) where it is cleaned. The cleaned
blood is returned to you through the other tubing.
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Peritoneal Dialysis
What is peritoneal dialysis?
In peritoneal dialysis (PD), your blood is cleaned inside your
body, not outside your body. The lining of your abdomen
(the peritoneum) acts as a natural filter.
A cleansing solution, called dialysate, flows into your
abdomen (your belly) through a soft tube called a PD
catheter. The PD catheter is placed during minor surgery.
Wastes and extra fluid pass from your blood into the
cleansing solution.
After several hours, you drain the used solution from your
abdomen and refill with fresh cleansing solution to begin the
process again. Removing the used solution and adding fresh
solution takes about a half hour and is called an “exchange.”
Peritoneal dialysis can be done at home, at work, at school,
or even during travel.
Peritoneal dialysis is a home-based treatment. Many people
who choose peritoneal dialysis feel it allows them greater
flexibility and independence.
TIP
Peritoneal dialysis might be a good choice if you:
•live far from a clinic or have no reliable transportation
to a dialysis center
•are working or are in school
•like to travel
•prefer to be in control of your treatment
•fear needles
•are soon expecting a transplant
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NATIONAL KIDNEY FOUNDATION
Are there different types of peritoneal dialysis?
Yes. The major ones are:
•Continuous Ambulatory Peritoneal Dialysis (CAPD). With
CAPD, you do the exchanges yourself 4 to 6 times a day.
•Automated Peritoneal Dialysis (APD). With APD, a
machine called a cycler does the exchanges automatically
once you have set up the equipment. APD can be done
while you sleep. However, if you do APD, you may also
need to do 1 or 2 exchanges yourself during the day
to make sure enough wastes and extra fluid are being
cleared from your blood.
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Kidney Transplant
What is a kidney transplant?
A kidney transplant is an operation that places a healthy
kidney from another person into your body. The kidney
may come from someone who has died or from a living
person who may be a close relative, spouse, or friend. It can
even come from someone who wishes to donate a kidney
to anyone in need of a transplant. Your new kidney will
be placed in your lower abdomen and connected to your
bladder and blood vessels.
The transplant operation takes about 3 hours and you will be
in the hospital for about 5 to 7 days. After the transplant, you
will need to take special medications to prevent your body
from rejecting the new kidney. You will have to take these
medications for as long as you have the transplant. Many
patients prefer a transplant over dialysis because it gives
them more freedom, allows for a less restricted diet and may
improve the quality and length of life.
A kidney transplant is a treatment, not a cure. A person with
a kidney transplant still has kidney disease, and may need
some of the other medicines they took before the transplant.
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Could I get a transplant before going on dialysis?
Yes. In fact there are long-term benefits of having a transplant
without having dialysis first. Your healthcare professional can
refer you to a transplant center for tests. Or you can contact
a local transplant center directly. (To locate a transplant
center, see page 25.) If a family member or friend is willing to
donate a kidney, the tests can be started right away. If there is
a “match,” surgery can be scheduled. However, if you do not
have a living donor, you will need to be on a waiting list until
a kidney from a suitably matched deceased donor becomes
available. In the meantime, you can have dialysis treatments.
Living With Your Treatment Choice
Will I feel better after I start treatment?
Once you get used to your treatment, you should begin to
feel better. The dialysis treatments or transplanted kidney will
take over some of the work of your damaged kidneys and
remove wastes and extra fluid from your body. This will make
many of your symptoms better.
If I choose one type of treatment for kidney failure,
will I be able to change to another type?
If you start on one type of treatment but feel you would
like to try something else, you can speak to your healthcare
professional about the possibility of changing. For example,
if you choose hemodialysis, it doesn’t mean you can’t ask to
switch to peritoneal dialysis at a later date. Even if you choose
to have a kidney transplant, you may need a period of dialysis
until you can be transplanted with a new kidney. It is not
uncommon for people who have had kidney failure for many
years to have had more than one type of treatment in that time.
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Will I need to take special medications?
You may need to take:
•Phosphate binders. These medicines keep your bones
strong by helping your body keep the right balance of
two important minerals—calcium and phosphorus.
•A special prescription form of vitamin D. This medicine
also helps to keep your bones healthy.
•Drugs called ESAs (erythropoiesis-stimulating agents).
ESAs act like a natural hormone made by your kidneys
called erythropoietin. This hormone tells your body to
make red blood cells. Not having enough of it can cause
anemia (low red blood cell count). Treatment with an ESA
can help your body make red blood cells.
•Extra iron. Your body also needs iron to make red blood
cells, especially if you are receiving ESAs. Without enough
iron, your ESA treatment will not work as well.
TIP
Part of the reason you feel so tired may be because
of anemia (low red blood cell count). Treatment to
correct anemia will help you to feel stronger and have
more energy.
•Vitamin and mineral supplements. You may need to
replace some vitamins and minerals that you are not
getting in your diet, or that are lost during dialysis. Your
healthcare provider or dietitian will tell you which ones
you need to take.
•Other medicines. You may need to take other medicines,
depending on your own medical needs. These could
be medicines to control high blood pressure, high
cholesterol, or diabetes.
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If you have a transplant, you may also need to take:
•Anti-rejection medicines. These medicines help to keep
your body from rejecting the new kidney.
Will my diet have to change?
Yes. The type of diet you follow will depend on the treatment
you receive. Your dialysis or transplant center will have a
dietitian who will help you plan your food choices to make
sure you are getting the right amount of protein, calories,
vitamins, minerals and fluids. The dietitian will help you make
a nutrition plan that helps you continue to enjoy your favorite
foods and be as healthy as possible.
Can exercise help me?
Yes. Exercise can help you feel stronger and improve your
overall well-being. Walking is good way to exercise. You
should speak to your doctor about an exercise program that
is right for you.
How long can I live on dialysis?
Now that we know more about how to care for people with
kidney failure, they live longer, feel better, and have more
active lives. Your overall health and how well you follow
your treatment plan are important in how well you do. If
you choose dialysis, it is important to get the right dose of
dialysis. Studies have shown that dialysis patients do better
and live longer when they get enough treatment. Your dialysis
care team can measure how much dialysis you receive. This
should be done on a regular basis to make sure treatments
are cleaning enough wastes out of your blood.
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Can I work if I am on dialysis or have a transplant?
Yes. It is possible to work with dialysis or after a transplant.
Returning to work may help you feel more positive and
independent. If you get in-center dialysis, the staff may be
able to arrange your treatments to fit your work schedule.
If you do home dialysis, you can fit your treatments into
your own schedule.
TIP
To learn more about treatment choices for kidney failure,
speak to your doctor or other members of your healthcare
team. Ask them to arrange for you to meet with a person
who is on dialysis or who has had a kidney transplant. If
information seminars are available, try to attend—and take
a family member or close friend.
What insurance coverage is available?
Many of the costs of dialysis and kidney transplant are covered
by the federal government through Medicare. Medicare is not
just for people who are 65 and older. The program also helps
Americans and legal residents of all ages who need dialysis or
a kidney transplant and qualify for coverage.
People with kidney failure can enroll in Medicare at their local
Social Security office, or by calling 800.772.1213 and making
an appointment to enroll. Before signing up, your dialysis
clinic or transplant program must complete a form and have
it signed by your doctor, verifying you have started dialysis
or received a kidney transplant. To find your local office,
look for Social Security Administration in the government
pages of your phone book or go to www.socialsecurity.gov/
locator.
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NATIONAL KIDNEY FOUNDATION
When does Medicare begin to pay?
Medicare will begin to cover dialysis treatments or a kidney
transplant when:
•You start your third full month of in-center hemodialysis
•You start a home dialysis training course at a Medicareapproved facility within the first three months of
treatment, and you plan to do home dialysis
•You are admitted to a Medicare-approved hospital for a
transplant, or up to two months before admittance if
pre-transplant healthcare and testing are begun
•You are already on Medicare
How much will Medicare cover?
Medicare may pay up to 80% of the costs associated with
dialysis and kidney transplant. But Medicare alone is not
enough. Many other sources of coverage are available to help
pay for what Medicare does not cover, including:
•Employer health insurance, private health insurance,
COBRA
•State programs such as Medicaid and high-risk
insurance pools
•Veteran’s benefits
•State kidney programs
•Medigap (Medicare supplemental health insurance)
To learn more about all your options for insurance coverage,
you can speak to:
•Your state insurance commissioner and ask what options
are available to you where you live
•An independent insurance broker
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•The NKF Cares Patient Help Line toll-free at
855.NKF.CARES (855.653.2273) or email
[email protected]
•A financial aid coordinator at your dialysis center
or transplant center
•Your county or state social service department
or Medicaid office
Does Medicare pay for home hemodialysis?
The federal government’s Medicare program covers the cost
of home hemodialysis just as they do for dialysis in a hospital
or other treatment center. However, Medicare will not cover
the cost of a home health aide if you have no one who can
be a care partner for you.
How can my family and I cope with kidney failure?
You and your family may have difficulty accepting the changes
in your lives caused by kidney failure, which can be a lot to
handle. You may have feelings of frustration, guilt, denial,
anger and depression. You and your family may find it helpful
to share your questions and concerns with each other and with
people who are willing to offer support. These can include
close friends and members of the healthcare team. The social
worker at your dialysis center is trained to provide counseling
to help you make the transition to dialysis or transplantation.
Some of the biggest changes are:
•getting used to a new routine with peritoneal dialysis
or hemodialysis
•following your diet and nutrition plan
•taking all your medicines exactly as instructed by your
doctor (including anti-rejection medicines if you have
a transplant)
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•continuing with your work, studies, school, family
commitments, and hobbies
The healthcare team (social workers, dietitians, doctors,
nurses, technicians, and other staff) are trained to help you
make these changes and to help you understand all areas
of your care.
Is it normal to have fears about beginning treatment?
Yes. It is normal to have concerns about how you will feel,
whether the treatment will hurt, what the staff and other
patients will think of you, and how long you can live with
the disease.
The following steps can help you cope with your feelings:
•Ask your healthcare provider if you can visit a dialysis
center. Visiting the center can help you make choices.
•If you are interested in a kidney transplant, ask your
healthcare provider for a referral to a transplant center.
Set up an appointment to visit with the staff and make
a list of questions.
•Speak to others who have been through the same
experience.
•Discuss all your concerns with the healthcare team
at the treatment center.
•Call your local National Kidney Foundation (NKF) office
for information and a list of the programs and services
available. Find your local NKF office by visiting the
NKF website at www.kidney.org or by calling the
NKF Cares Patient Help Line toll-free at 855.NKF.CARES
(855.653.2273) or emailing [email protected]
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For More Information
To learn more about treatments for kidney failure, call the
National Kidney Foundation’s NKF Cares Patient Help Line
toll-free at 855.NKF.CARES (855.653.2273) or email
[email protected] or visit www.kidney.org
You may be interested in asking for a free copy of the
following National Kidney Foundation’s booklets:
Coping Effectively: A Guide for Patients and Their Families
Order# 11-10-0503
Getting Ready for a “New Normal”: A Helpful Guide for
Starting Dialysis
Order# 11-10-0307
Hemodialysis: What You Need to Know
Order# 11-50-0214 [Spanish #11-50-0219]
Hemodialysis Access: What You Need to Know
Order# 11-50-0216 [Spanish #11-50-0220]
Kidney Transplant
Order# 11-10-0304
Nutrition and Kidney Failure: Are You Getting What You Need?
Order# 11-50-0115
Peritoneal Dialysis: What You Need to Know
Order# 11-50-0215 [Spanish #11-50-0221]
Staying Fit with Kidney Disease
Order# 11-10-0502
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Taking Control: Money Matters for People with Chronic
Kidney Disease
Order# 01-10-0250
Working with Kidney Disease
Order# 11-10-0501
You may also be interested in these helpful websites:
For hemodialysis vascular access: www.fistulafirst.org
For Medicare information: www.medicare.gov
For Social Security benefits information:
www.socialsecurity.gov
For information on kidney disease:
www.kidney.org/kidneydisease
For information on transplantation:
www.kidney.org/transplantation or www.unos.org
And learn more at www.kidney.org
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Notes
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NATIONAL KIDNEY FOUNDATION
The National Kidney Foundation is the leading organization in the U.S.
dedicated to the awareness, prevention, and treatment of kidney disease for
hundreds of thousands of healthcare professionals, millions of patients and their
families, and tens of millions of Americans at risk.
Help fight kidney disease.
Learn more at www.kidney.org
30 East 33rd Street
New York, NY 10016
800.622.9010
© 2013 National Kidney Foundation, Inc. 11-10-0352_IBD